A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?

BMI of 20

Peripheral neuropathy

Immobility

Hypoperfusion

Prealbumin level of 16 mg/dL

Answer and Explanation

Correct Answer : B,C,D,E

A. BMI of 20:
A BMI of 20 is within the normal range. While extremes of BMI, either low or high, can contribute to health issues, a BMI of 20 alone may not significantly increase the risk of pressure injuries.

B. Peripheral neuropathy:
Peripheral neuropathy, which involves damage to the nerves in the extremities, can lead to decreased sensation and awareness. Clients with peripheral neuropathy may have difficulty sensing pressure, friction, or discomfort, making them more susceptible to pressure injuries.

C. Immobility:
Immobility is a significant risk factor for pressure injuries. Clients who are unable to change positions frequently are more likely to develop pressure points, particularly over bony prominences. Regular repositioning is essential to prevent pressure injuries in immobile individuals.

D. Hypoperfusion:
Hypoperfusion, or inadequate blood flow to tissues, can compromise tissue viability. Proper blood circulation is crucial for delivering oxygen and nutrients to the skin and underlying tissues. Impaired perfusion can contribute to tissue damage and increase the risk of pressure injuries.

E. Prealbumin level of 16 mg/dL:
Prealbumin is a marker of nutritional status. A low prealbumin level (16 mg/dL) indicates malnutrition, which can impair the body's ability to repair and maintain tissues, including the skin. Malnourished individuals are at an increased risk of developing pressure injuries.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Fluid volume overload:
Explanation: Fluid volume overload is not typically associated with urinary incontinence. It is more commonly linked to conditions affecting the heart and kidneys.

B. Kidney stones:
Explanation: Kidney stones are not directly related to urinary incontinence. Kidney stones may cause pain, hematuria (blood in urine), and changes in urinary frequency.

C. Dermatitis:
Explanation: This is correct. Urinary incontinence can lead to skin irritation and dermatitis, especially if the skin is constantly exposed to urine. Keeping the perineal area clean and dry is important to prevent dermatitis.

D. Hypoglycemia:
Explanation: Hypoglycemia is not typically associated with urinary incontinence. It is more related to low blood sugar levels and is not a direct consequence of urinary incontinence.

A. The nurse administers the feeding through a syringe barrel by gravity. B. The nurse allows the client to rest in a supine position during feeding. C. The nurse irrigates the NG tube with tap water after feeding. D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.

Correct Answer is B

Explanation

A. The nurse administers the feeding through a syringe barrel by gravity.
This is an appropriate method for administering intermittent tube feedings. Gravity feeding with a syringe allows for controlled delivery of the feeding solution.

B. The nurse allows the client to rest in a supine position during feeding.
Feeding a client in a supine position is generally acceptable, especially if the client is comfortable and doesn't experience complications. However, if there are specific contraindications or concerns for aspiration, the nurse should follow the prescribed position guidelines.

C. The nurse irrigates the NG tube with tap water after feeding.
Using tap water to irrigate an NG tube is not recommended, as it may lead to complications such as electrolyte imbalances. Sterile or distilled water should be used for irrigation.

D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
This is an appropriate action. Aspirating gastric residual before initiating a feeding helps assess the presence of gastric contents, ensuring that the client is ready to receive the feeding. However, specific institutional policies may dictate the threshold for gastric residual volume that requires intervention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data on a client. Which of the following findings increase the client's risk of a pressure injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?

Correct Answer is C

Explanation

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

Correct Answer is B

Explanation

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?

A nurse is collecting data from a client who has an inadequate dietary intake of fiber. Which of the following findings should the nurse expect?

A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

A nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?